The Transtheoretical Model of Change (Prochaska, DiClemente, & Norcross, 1997) and Motivational Interviewing (Rollnick, Miller, & Butler, 2012) are techniques used to understand and implement behaviour change in a therapeutic setting. It is important that we as health care practitioners provide support and assistance to clients who are overweight or obese to address the underlying cause of many chronic diseases. (Kushner & Ryan, 2014) Harry is a 58-year-old chef whose persistent high weight is impacting his health. Overweight and obesity account for 67% (Overweight and obesity: an interactive insight, 2019) of Australia’s population and is one of the country’s nine National Health Priorities. Specifically, obesity is more prevalent in foodservice employees (Pizam, 2013). In this essay I will firstly define the stages of the proposed models, where this case fits within them, and then define how best to utilise Motivational Interviewing in changing Harry’s situation towards better health habits in the four days he is within my care. The Transtheoretical Model of change (Prochaska, DiClemente, & Norcross, 1997), from herein referred to as ‘TTM’, proposes a cognitively based therapy to support progress to more therapeutic actions that are ongoing. It is defined by five progressive stages with an extra stage for relapse and termination option. Movement does not need to progress forward, but the aim is to do so. The stage of ‘pre-contemplation’ is defined as the person not considering, showing interest or recognising the need to change. They may not even know or think it is possible or necessary. In Harry’s situation, I believe this is where we might place him. He states “I’ve been overweight for years and that’s just how I am.” This gives me the impression of denial and a person-centred mentality to his current weight situation. At this stage I would build a rapport with Harry and ask some open-ended questions that may lead to awareness and thought about the benefits of some lifestyle changes. I will address this more in-depth later in relation to Motivational Interviewing. The next stage in this model is ‘contemplation’ where the person is aware and may have intention or is thinking about modifying their behaviour. Often this is brought about by an incident and although I feel Harry is not quite at this point, I feel he is close. He is aware his doctor has concerns and potentially Harry’s surgery tomorrow will have the effect of triggering more thought and consideration, but perhaps still with some ambivalence. Positive feedback is of great benefit at this time. Should Harry progress through this ambivalence, he may then start thinking about actual change. That would then move Harry into the model’s ‘preparation’ stage defined as an intention or commitment to change. Harry may start making plans to try and integrate a healthier lifestyle into his everyday life. He may book to see a dietitian or start walking to work. Encouragement and help adapting these modifications comfortably into his timetable would support this stage that may take up to 30 days before it is beneficial, and action occurs. The stage of ‘action’ is when these new planned changes are adopted and are showing therapeutic benefit. This initiation will still need effort and determination and may last up to 3-6 months. Harry, at this point, might need his commitment strengthened and acknowledgment of the steps he has taken. If possible, Harry would be motivated to avoid people or places that may negatively affect his progress. The goal stage of TTM is ‘maintenance’ and occurs when there is ongoing, sustained, integrated practice of the new health behaviour. For some people this stage may be the completion of the TTM model as the outcome has now been reached (termination). In Harry’s case this would be an ongoing exercise and support may be to encourage him to share his experiences and connect with others in a peer support environment. If Harry was in my care at this time I may offer him some research like the movement of chef’s making menu changes in their workplace (Obbagy, Condrasky, Roe, Sharp, & Rolls, 2011). The effort now is to protect against relapse. Relapse can happen at any stage. Barkway (2013) states ‘When relapse occurs the person is encouraged to view this as part of the cycle of change, not failure – a challenge not a catastrophe.’ The relapse can revert the person to any of the aforementioned stages and should be readdressed with the support applicable to that stage. For Harry we may also have a relapse plan built into each stage that may account for holidays, busy times at the restaurant or even changing his job. Given Harry’s age, it may also be applicable to think about Harry’s retirement and how that may impact his lifestyle. As previously mentioned, I would place Harry at the ‘pre-contemplation’ stage due to his denial of there being an issue. I will now address how I can utilise Motivational Interviewing to support him and help him move in the direction of ‘maintenance’. Motivational Interviewing (Rollnick, Miller, & Butler, 2012), from herein referred to as ‘MI’, like TTM, encourages the practitioner to support and guide the client themselves to realise the need for change. This requires the client to recognise their own ambivalence and their readiness to grow with interaction with their practitioner. The interaction is generally quiet, with the practitioner encouraging resolution to the ambivalence in partnership with the client. This method of intervention has been shown to influence physical behaviour in a positive way. (Rodriguez-Cristobal, et al., 2017) The mind- and heart-set of MI is called the ‘Spirit of Motivational Interviewing’ and is made up of some key elements that seek to avoid trying to manipulate clients into our own agenda. (Rollnick, Miller, & Butler, 2012). These elements consist of partnership, acceptance, compassion and evocation. With these elements in mind, I would address supporting Harry by considering the four stages of MI. When first meeting Harry I would seek to engage his trust and build a relationship. Introducing myself and my capacity within the surgical ward with my intention to be caring for him for the next four days. Some open-ended questions of engagement may be around how he is feeling, what keeps him busy out of hospital, family and social connections, and even just chat about the weather. I may also try to find some similarities or understanding in my own life to reflect back without getting too personal. Acceptance and compassion here may be prevalent and listening for any uneasiness leading up to his hip surgery tomorrow. I might also be listening during the day for some opportunity to ask him if the reasons for his impending surgery have had much impact on his life and if perhaps there was anything he might change to lesson that impact. This may open an opportunity for me listen for change talk and to offer myself to support him with some ideas to perhaps think about until tomorrow. When caring for Harry the following day, post his surgery, we may then look at focusing in on some more specific issues. Harry may have now transitioned from the TTM ‘pre- contemplation’ to ‘contemplation’ stage and is more open or showing desire to change. Responding to Harry with a question like ‘I’m hearing that you feel your weight is normal for someone working in your profession around food all day. Can you tell me a little bit about this?’ The answer may then give us a direction or focus to develop discrepancy and, pending readiness, look at ways to change. I might also hand him some information about the increased risks of other diseases associated with his condition to give him an opportunity to inform himself during his recovery time at the hospital. With this direction and focus in mind, we might then try to discover Harry’s own motivation to evoke the realised necessary changes. I would help him gather his own ideas and feelings about how he might accomplish these. Asking him questions about what he thought about the information I had given him previously, how he has overcome things in the past, and for the things that have not worked, does he know how they could be modified. This would be a collaborative discussion with me motivating him to find positive behaviours and feeding back positive affirmations This focus and goal finding exploration may take a few days of conversation and consultation that I would address with Harry using open ended questions, positive affirmations of progress and decisions, reflection and summary of what I have heard and understood of his communication. Before my four days come to an end, I would reflect back to Harry any plans that he had spoken about and if they were specific, measurable, achievable, relevant and timed, and would again offer affirmations and motivations to continue on the path he is on into the future. In summary, moving Harry from an external ‘locus of control’ style (Rotter, 1966), into a more ‘internal’ state of self-efficacy where he can feel able to modify his behaviour rather than him just feeling ‘that’s just how I am... I am around food all day long’ is a positive goal to have within the four days of my care. This can be accomplished very effectively utilising the Transtheoretical Model of change and Motivational Interviewing (DiLillo & West, 2011). Addressed in partnership and with acceptance, compassion and evocation, Harry can be well supported on his way to maintenance. Bibliography
Barkway, P. (2013). Psychology for health professionals (2nd ed.). Sydney, N.S.W.: Churchill Livingstone/ Elsevier. DiClemente, C. C., Shumann, K., Greene, P. A., & Earley, M. D. (2011). A transtheoretical model perspective on change: process-focussed intervention in mental health- substance use. In D. B. Cooper, Intervention in Mental Health-Substance Use (pp. 69- 87). London: Radcliffe Publishing. DiLillo, V., & West, D. S. (2011). Motivational Interviewing for Weight Loss. Psychiatric Clinics of North America, 861-869. https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an-interactive- insight, A. I. (2019). Overweight and obesity: an interactive insight. Retrieved from Australian Institute of Health and Welfare: https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an- interactive-insight Kushner, R. F., & Ryan, D. H. (2014, September 3). Assessment and Lifestyle Management of Patients With Obesity Clinical Recommendations From Systematic Reviews. JAMA, 312(9), 943-952. Obbagy, J. E., Condrasky, M. D., Roe, L. S., Sharp, J. L., & Rolls, B. J. (2011, February). Chefs’ Opinions about Reducing the Calorie Content of Menu Items in Restaurants. Obesity Journal, 19(2), pp. 332-337. Pizam, A. (2013, March). The prevalence of obesity among foodservice employees. International Journal of Hospitality Management, 32, 1. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1997). In search of how people change: applications to addictive behaviors. In A. G. Marlatt, & G. R. VanderBos, Addictive behaviors: Readings on etiology, prevention, and treatment (pp. 671-696). Washington, D.C.: American Psychological Association. Riekert, K. A., Borrelli, B., Bilderback, A., & Rand, C. S. (2011, January). The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Education and Counseling, 82(1), 117-122. Rodriguez-Cristobal, J. J., Alonso-Villaverde, C., Panisello, J. M., Travé-Mercade, P., Rodriguez-Cortés, F., Marsal, J. R., & Peña, E. (2017, June 20). Effectiveness of a motivational intervention on overweight/obese patients in the primary healthcare: a cluster randomized trial. BMC Family Practice. Rollnick, S., Miller, W. R., & Butler, C. C. (2012). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guildford Press. Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs 80. VanBuskirk, K. A., & Wetherell, J. L. (2013, August 11). Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med, 768- 780.
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